2004-979 L; TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE '
Permit Number: P20040979 Date Issued: Monday, December 27, 2004
This is to certify that work requested to be done as shown by Permit Number P20040979
has been completed.
Tax Map Number: 523400-304-017-0001-052-000-0000
Location: 8 BELLE Ave
Owner: LAURA G WILCOX
Applicant: LAURA G WILCOX
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building&CocYe Enforcement
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit'Number: P20040979 Application Number: , A20040979
Tax Map No: 523400-304-017-0001-052-000-0000
Permission is hereby granted to: LAT TRA G WILCOX
For property located at: 8 BELLE Ave
in the Town of Queensbury,to construct or place
at the above location in accordance with application together with plot plans and other information hereto filed
and approved and in compliance with the NYS Uniform Building Codes and the Queensbury Zoning
Ordinance. Type of Construction Value
Owner Address: LAURA G WILCOX
8 BELLE Ave Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
T.B.S. SEPTTC
2 LOWER WARREN STREET
OTTEENSBTTRY_ NY
Plans&Specifications
2004-979
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday, December 22, 2005
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the Town o uee,l s u ay, December 22, 2004
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
Application for Permit-Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
C �" ........................................... ..Office Use..
Location of installation: b
i
File Permit No. 0 9—
7
Tax Map No.
i Fee Paid
Owner's Name: 6ck ,/`C., L r �C d
..•.....•..•.......•...............•.....•.•..... ....•,..........•..............................••,•..,,...............•....
Address: it A— ff A CC-
..:
2. INSTALLER'S NAME ` �� > 1p" PHONE NO.
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate#bedroom(s) and multiply#of
bedrooms with applicable gallons per bedroom to equal total daily flow)
Year of House: No. of Bedrooms x Computation = Total Daily Flow
1980 or older 3 x 150 gal/bdrm = 1(s D
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm = in Im
Garbage Grinder Installed yes_ / no:' .'Ve®
Spa or Hot Tub Installed yes_ / no `n 2
2
TOWN OF QUEENS& RY
4: PARCEL INFORMATION: (circle applicable information&indicate measureme L,gNNING OF�ID�
7olling
h S ' e Ground Water Bedrock or Impervious Material es tic ter So ply
(Zs:nd a wh t depth atwhst epth municipal
feet /tom' et w
Steep slope clay if well; water supply
_%slope other from any septic-system
depth: absorption is ft.
other
Percolation Test: (To be completed by licensed professional engineer or architect)-
Rate: minute per inch
5. PROPOSED SYSTEM: For New Construction: All individual sewage disposal systems must be designed by a licensed
professional engineer or architect(unless installed in a Planning Board approved subdivision). Add 250 gallons to the size
of the septic tank and leach field for each Garbage Grinder, Spa or Whirlpool Tub.
Septic Tank: gallon (min. size 1,000 gal.)
Tile Field: each trench_ ft. Total System Leng l ft.
Seepage Pit(s): number of size of each: ft. by ft.
Size�f Stone to be used: # / depth or thickness feet
Bed System Size: x
Alternative System: length and/or size
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: / Size of each: gallons /TOTAL Capacity: gallons
Note: Alarm System and associated electrical work must be inspected by a Town approved
electrical inspection agency.
7. SIGNATURE &INFORMATION FOR RESPONSIBLE PERSON(please read)
For your protection,please note that pursuant to Section 136-29 of the Code of the Town
of Queensbury, any permit or approval granted which is based upon or is granted in
reliance upon any material misrepresentation or failure to make a material fact or
circumstance known by or on behalf of an applicant, shall be void.
I have read the regulations with respect to this application and agree to abide by these and all
requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
�A
of responsible person Date
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Septic Inspection Report
Office No. (518)761-8256 Date Inspectiof
eiv d:
Queensbury Building&Code Enforcement Arrive: epart: -�L,
742 Bay Rd., Queensbury,NY 12804 Inspector's Iniis
NAME: ITNO.:
.�
LOCATION: _ ON:
RECHECK:
Comments and/or diagram
Soil T .'Sand -am a ,
Type of unici a ell Water
Waterline se &ratio ance ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length v ft.
Length of each trench U - vft.
Depth of trenches L'— r;'ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size —Type
Building to tank I` 1--)C' Ll-c'
Tank to Distribution Box L-1 I L V 3
Distribution Box x6 e /Pit LA '� L`` ik
Opening SealeV Y /Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption 12 ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Location of System on Property:
Front Rear Left Side Right Side
Middle fiddle Rear Fr rft
System Use S tus:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:\.SueHe-mingway\Building.Codes.Inspection.FORMS1Septic Inspection Report.doc January 28,2003
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